CARIN Consumer Realtime Pharmacy Benefit Check Implementation Guide CI Build

CARIN Consumer Realtime Pharmacy Benefit Check - Local Development build (v0.1.00-DRAFT). See the Directory of published versions

SD.7 StructureDefinition-carin-rtpbc-request-Claim

title: StructureDefinition-carin-rtpbc-request-Claim-intro layout: default active: StructureDefinition-carin-rtpbc-request-Claim-intro —

This profile constrains the Claim resource so that it can serve as the RTPBC Request in the consumer real-time pharmacy benefit check process

SD.7.1 Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/carin/StructureDefinition/carin-rtpbc-request

Published on Thu Oct 03 00:00:00 CDT 2019 as a draft by CARIN Alliance.

This profile builds on Claim

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*
... id S1..1stringUnique Claim Resource Identifier
... identifier S1..1IdentifierRTPBC request identifier
.... value S1..1stringUnique RTPBC request ID
... status S1..1codeRequest status
Fixed Value: active
... type S1..1CodeableConceptRequested Service Type
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display1..1stringRepresentation defined by the system
Fixed Value: Pharmacy
.... coding S1..1Coding
..... system S1..1uri
..... code S1..1code
... subType 0..0
... use S1..1codeProcessing Mode
Fixed Value: predetermination
... patient S1..1Reference(CARIN RTPBC Request Patient Info)Request Patient Information
.... reference S1..1stringPatient Reference
... billablePeriod 0..0
... created S1..1dateTimeCreated DateTime
... enterer 0..0
... provider S1..1Reference(CARIN RTPBC Pharmacy)Preferred Pharmacy
.... reference S1..1stringReference to Pharmacy Organization
... priority S1..1CodeableConceptProcessing priority
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
.... coding S1..1Coding
..... system S1..1uri
..... code S1..1code
... fundsReserve 0..0
... related 0..0
... originalPrescription 0..0
... payee 0..0
... referral 0..0
... facility 0..0
... careTeam S1..1BackboneElementCare Team
.... sequence S1..1positiveIntFixed Value: 1
.... provider S1..1Reference(CARIN RTPBC Request Prescriber Info)Prescriber
..... reference S1..1stringPrescriber Reference
... supportingInfo 0..0
... diagnosis 0..0
... procedure 0..0
... insurance S1..1BackboneElementPharmacy Coverage
.... sequence S1..1positiveIntFixed Value: 1
.... focal S1..1booleanFixed Value: true
.... coverage S1..1Reference(CARIN RTPBC Request Coverage Identifiers)Pharmacy Coverage Reference
..... reference S1..1stringPharmacy Coverage Reference
... accident 0..0
... item S1..1BackboneElementMax 1 item per request
.... sequence S1..1positiveIntFixed Value: 1
.... careTeamSequence S1..1positiveIntCare Team Sequence ID Reference
.... revenue 0..0
.... category 0..0
.... productOrService S1..1CodeableConceptPrescribed Product
Binding: CARIN RTPBC Prescribable Product Code Value Set (extensible)
..... coding S1..*Coding
...... system S1..1uri
...... code S1..1code
...... display S1..1stringProduct Description
.... modifier 0..0
.... programCode 0..0
.... serviced[x] 0..0
.... location[x] 0..0
.... quantity S1..1SimpleQuantityPrescribed Quantity
..... value S1..1decimalQuantity in Billing Units
..... unit S1..1stringBilling unit of measure
Binding: CARIN RTPBC Billing Unit Value Set (required)
.... unitPrice 0..0
.... factor 0..0
.... net 0..0
.... bodySite 0..0
.... subSite 0..0
.... encounter 0..0
.... detail 0..0
... total 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim I0..*Claim, Pre-determination or Pre-authorization
... id SΣ1..1stringUnique Claim Resource Identifier
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..1IdentifierRTPBC request identifier
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type ΣI0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣI1..1stringUnique RTPBC request ID
Example General: 123456
.... period ΣI0..1PeriodTime period when id is/was valid for use
.... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣI1..1codeRequest status
Binding: FinancialResourceStatusCodes (required)
Fixed Value: active
... type SΣI1..1CodeableConceptRequested Service Type
Binding: ClaimTypeCodes (extensible)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display1..1stringRepresentation defined by the system
Fixed Value: Pharmacy
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣI1..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code SΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... use SΣI1..1codeProcessing Mode
Binding: Use (required)
Fixed Value: predetermination
... patient SΣI1..1Reference(CARIN RTPBC Request Patient Info)Request Patient Information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringPatient Reference
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... created SΣI1..1dateTimeCreated DateTime
... insurer ΣI0..1Reference(Organization)Target
... provider SΣI1..1Reference(CARIN RTPBC Pharmacy)Preferred Pharmacy
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringReference to Pharmacy Organization
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... priority SΣI1..1CodeableConceptProcessing priority
Binding: ProcessPriorityCodes (example)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣI1..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code SΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... prescription I0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... careTeam SI1..1BackboneElementCare Team
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntOrder of care team
Fixed Value: 1
.... provider SI1..1Reference(CARIN RTPBC Request Prescriber Info)Prescriber
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣI1..1stringPrescriber Reference
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... responsible I0..1booleanIndicator of the lead practitioner
.... role I0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example)
.... qualification I0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... insurance SΣI1..1BackboneElementPharmacy Coverage
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣI1..1positiveIntInsurance instance identifier
Fixed Value: 1
.... focal SΣI1..1booleanCoverage to be used for adjudication
Fixed Value: true
.... identifier I0..1IdentifierPre-assigned Claim number
.... coverage SΣI1..1Reference(CARIN RTPBC Request Coverage Identifiers)Pharmacy Coverage Reference
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣI1..1stringPharmacy Coverage Reference
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... businessArrangement I0..1stringAdditional provider contract number
.... preAuthRef I0..*stringPrior authorization reference number
.... claimResponse I0..1Reference(ClaimResponse)Adjudication results
... item SI1..1BackboneElementMax 1 item per request
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntItem instance identifier
Fixed Value: 1
.... careTeamSequence SI1..1positiveIntCare Team Sequence ID Reference
.... diagnosisSequence I0..*positiveIntApplicable diagnoses
.... procedureSequence I0..*positiveIntApplicable procedures
.... informationSequence I0..*positiveIntApplicable exception and supporting information
.... productOrService SI1..1CodeableConceptPrescribed Product
Binding: CARIN RTPBC Prescribable Product Code Value Set (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI1..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣI1..1uriIdentity of the terminology system
...... version ΣI0..1stringVersion of the system - if relevant
...... code SΣI1..1codeSymbol in syntax defined by the system
...... display SΣI1..1stringProduct Description
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text ΣI0..1stringPlain text representation of the concept
.... quantity SI1..1SimpleQuantityPrescribed Quantity
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣI1..1decimalQuantity in Billing Units
..... unit SΣI1..1stringBilling unit of measure
Binding: CARIN RTPBC Billing Unit Value Set (required)
..... system ΣI0..1uriSystem that defines coded unit form
..... code ΣI0..1codeCoded form of the unit
.... udi I0..*Reference(Device)Unique device identifier

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron